Developing and validating the nurse-patient relationship scale (NPRS) in China

Background Poor nurse-patient relationship poses an obstacle to care delivery, jeopardizing patient experience and patient care outcomes. Measuring nurse-patient relationship is challenging given its multi-dimensional nature and a lack of well-established scales. Purpose This study aimed to develop a multi-dimensional scale measuring nurse-patient relationship in China. Methods A preliminary scale was constructed based on the existing literature and Delphi consultations with 12 nursing experts. The face validity of the scale was tested through a survey of 45 clinical nurses. This was followed by a validation study on 620 clinical nurses. Cronbach’s α, content validity and known-group validity of the scale were assessed. The study sample was further divided into two for Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA), respectively, to assess the construct validity of the scale. Results The Nurse-Patient Relationship Scale (NPRS) containing 23 items was developed and validated, measuring five dimensions: nursing behavior, nurse understanding and respect for patient, patient misunderstanding and mistrust in nurse, communication with patient, and interaction with patient. The Cronbach’s α of the NPRS ranged from 0.725 to 0.932, indicating high internal consistency. The CFA showed excellent fitness of data into the five-factor structure: χ2/df = 2.431, GFI = 0.933, TLI = 0.923, CFI = 0.939, IFI = 0.923, RMSEA = 0.070. Good content and construct validity are demonstrated through expert consensus and psychometric tests. Conclusion The NPRS is a valid tool measuring nurse-patient relationship in China. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-024-01941-w.


Introduction
At present, nurse-patient disputes are common, and a large number of reports focus on the relationship and conflicts between nurses and patients.Despite efforts to alleviate the strained relationship between nurses and patients, it still persists [1].Patients are usually considered as a passive subject [2,3].Research points out that many patients, or most of them, are not able to engage in care for themselves through effective interactions with health workers [4].Henderson [5] noted that professional domination over patient care causes depersonalization and, consequently, worsening of the relationship between the nurse and the patient [2,6].
A positive nurse-patient relationship is fundamental for effective and high-quality nursing care.The importance of defining and evaluating the connotation of the nursepatient relationship has been well-established, with a variety of theories being proposed [7][8][9].Some scholars define it as a kind of interpersonal relationship in the process of providing and receiving nursing services.Nurses and patients learn and encourage each other, naturally forming a relationship of helping and being helped [10].Others see it as instrumental, primarily reflecting the help nurses provide to patients [11].From the perspective of nurses, a positive nurse-patient relationship allows them to effectively plan, provide, and evaluate nursing services.For patients, the caring consciousness, wisdom, and interpersonal skills of nurses are essential for developing and maintaining a continuous nurse-patient relationship [12].Clinical and interpersonal skills are the two equally important pillars of patient-centered nursing practice [13].
It is critical for nurses to form a positive attitude towards patients that involves respect, trust, and understanding to enable effectively communication and delivery of the help and guidance needed by the patients [14].Empirical evidence suggests that the tension between nurses and patients is associated with a lack of respect and understanding of nursing care from patients.Some patients or the public may hold inherent prejudices toward the status and nature of nursing work, resulting in a lack of respect and understanding for nurses [15].This can manifest in behaviors such as not treating nurses with respect or understanding their role.In some extreme cases, patients may resort to verbal and even physical violence against nurses, which can have a negative impact on the nurse-patient relationship.As a result, the nurses may be unable to provide high-quality nursing services [16].
A reliable tool measuring nurse-patient relationship can not only help to better understand the nursing care process, but also predict patient experience and care outcomes [7][8][9].However, the existing validated tools measuring the nurse-patient relationship have several limitations.Firstly, there is a lack of comprehensiveness, with most focusing on specific selected aspects of the nurse-patient relationship, such as trust [17,18], social interaction [19], and care behavior [20].Secondly, there exists ambiguity in the conceptualization of the elements measured by the existing tools: for example, "respect" can be regarded as an attribute of trust [21] or nursing behavior [20,22].Thirdly, the existing tools have failed to consider the special circumstances of nursing work environments in China.The hierarchical and collectivist culture in China has significant implications for how nurses work with their patients and colleagues.Nurses often become an easy target for patient complaints although system problems are usually the underlying reasons [23].Therefore, there is a need to develop a measurement tool that can capture the complex nature of nurse-patient relationship, especially under the context of the Chinese health system [24].
This study aimed to address the gap in the literature by developing and validating a scale that measures the nurse-patient relationship comprehensively from the perspective of nurses in China, guided by existing theories and considering the existing measurement tools.

Methods
The study followed the best practice in scale development [25], which involved four steps: item generation, content verification, scale refinement, and reliability and validity assessment (Fig. 1).
The study was conducted in Heilongjiang, a province with a socioeconomic development index at the lower end range in China.In 2019, Heilongjiang had 26 nurses per 10,000 population, compared with a national average of 32 [26].

Item generation
The concept of nurse-patient relationship was defined as a therapeutic relationship in line with Peplau's interpersonal relationship theory.Nurses play a variety of roles in helping patients, ranging from a communicator to a caregiver [12].At the core of the relationship is trust, communication, mutual understanding, and clinical care.Halldorsdottir (2008) likened the two extremes of nursepatient relationship as "bridge" and "wall" [27]."Bridge" symbolizes openness of communication and connectivity felt by patients in their relationship with nurses.It represents patient-centeredness and easy access to nursing services.By contrast, "wall" symbolizes a lack of communication and indifference of nurses to patient demands, as well as mistrust between the two parties [27].The items generated in this study covered both "wall" and "bridge" aspects in relation to trust, communication, understanding, and clinical care.
The sources of items came from a cascading decomposition of the aforementioned theoretical assumptions, a review of the existing measurement tools, and descriptive adaptation to the local health system and clinical practices.A total of 12 sub-domains were mapped into the four core functions of nurse-patient relationship through the process, with advisory support from six external experts who had complementary knowledge and expertise to the research team (Table 1).

Content verification -Delphi consultations
The Delphi method is one of the most commonly used procedures to establish content validity of a scale [28].In this study, eligible participants of the Delphi consultations were the experts with a background of nursing research, clinical nursing, or psychology.A minimal of ten years of work experience in the relevant areas was required.The participants were recruited through a stratified convenience sampling strategy.In total, 12 experts from eight provinces participated in the Delphi consultations, covering the eastern developed, the central developing, and the western under-developed regions in China.Half of them worked in academic institutions and half in the healthcare industry.
The participants were invited to respond to the consultation questionnaire by email in December 2019.They were asked to rate the relative importance of each sub-domain on a five-point Likert scale ranging from 1 (disagree) to 5 (agree), and the relevance of each item to its respective sub-domain on a fivepoint Likert scale ranging from 1 (not relevant) to 5 (essential).Suggestions about modification, removal, or addition of items, sub-domains, and domains were also encouraged.Participation in the consultations was voluntary and verbal informed consent was obtained from each participant.Consensus of the expert ratings was indicated by the percentage of agreement.The items/sub-domains that had a higher than 80% expert agreement and an over 4 average score were retained [29].Two rounds of consultations were conducted.The first round resulted in some changes in the subdomains and items, although the four core functions (domains) remained unchanged.In round two, feedback of the round one results was provided, which included the rating results and the corresponding changes made such as removal, addition, and modification of items, sub-domains, and domains.Participants were asked to reconsider their ratings if needed.The 12 experts completed both rounds of consultations.
We also calculated the item content validity index (I-CVI) and the scale content validity index (S-CVI)/ average: I-CVI > 0.78 and (S-CVI)/average of 0.90 or higher were deemed acceptable [30,31].

Pilot testing
The NPRS endorsed by the experts was tested in a convenience sample of 45 nurses selected from the clinical units (mainly internal medicine, surgery, ICU, and stomatology) of a tertiary hospital in Harbin, capital of Heilongjiang province.Participants were asked to self-complete the paper questionnaire independently.Cronbach's α coefficient of the scale reached 0.795.No further changes were made as a result of the pilot testing.

Reliability and validity assessment
Reliability and validity of the NPRS were assessed through a questionnaire survey of clinical nurses in a public tertiary hospital in Qiqihar city in Heilongjiang province.The hospital employed 1093 clinical nurses who had direct contacts with patients.From 29 to 31 December 2019, the nurses working in the clinical units were invited to participate in the survey.Participation in the survey was anonymous and voluntary.Return of the questionnaire was deemed informed consent.In total, 721 questionnaires were distributed and 708 (86.5%) were returned.After removal of the invalid returned questionnaires, 620 (86.0%) were included for data analysis, representing 56.7% of the entire nursing workforce in the participating hospital.

Ethical considerations
Ethics approval for the study protocol was granted by the research ethics committee of Harbin Medical University.

Data analysis
Data were analyzed using SPSS 21.0 and AMOS 24.0.A two-sided p value of less than 0.05 was considered statistically significant.A pairwise strategy was adopted in managing missing values.
Each item of the NPRS was rated on a five-point Likert scale, ranging from 1 (Strongly disagree) to 5 (Strongly agree).The direction of item scores was aligned before a summed score was calculated for each domain and the entire scale, with a higher score indicating a more positive nurse-patient relationship.
Construct validity was tested through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).The study sample was randomly divided into two mutually independent sub-samples, with 330 participants for EFA and 290 participants for CFA, respectively.The appropriateness of factor analyses was assessed using the Kaiser-Meyer-Olkin (KMO) measure (KMO ≥ 0.50) and Bartlett's test of sphericity (p < 0.05) [32].The EFA extracted factors with an eigenvalue greater than 1 using principal component analysis (PCA) with maximal rotation of variance.This allowed us to identify and eliminate poorly-fitted items, including those with a low factor load (< 0.4) on all factors and those with a high load (≥ 0.4) across multiple factors [33].The CFA then assessed the fitness of data into the adjusted scale resulting from the EFA.A good model fit was indicated by Chi-square/ degree of freedom (χ 2 /df ratio ranging from 1 to 3), goodness-of-fit index (GFI > 0.9), root mean square error of approximation (RMSEA < 0.08), a root mean square residual (RMR < 0.08), a comparative fit index (CFI > 0.9), a normalized fit index (NFI > 0.9), and Incremental Fit Index (IFI > 0.9) [34].Convergent validity was assessed by composite reliability (CR > 0.70) [35] and average variance extracted (AVE > 0.5) from CFA [36].Discriminant validity was assessed by comparing AVE with the Pearson correlation coefficients between domains: A good discriminant validity is indicated if the square root of AVE of each construct is greater than its correlations with the rest of the constructs [37,38].
Reliability was assessed by Cronbach's α for the entire NPRS and its domains using the entire sample.A greater than 0.7 Cronbach's α coefficient indicates good internal consistency [39].
Known-group validity was tested through student t tests using the entire sample, with a hypothesis that nurse-patient relationship varies by the personal characteristics of the nurse [40,41].

Characteristics of Delphi participants
About one third of the participants of the Delphi consultations came from Heilongjiang province and over 40% aged between 30 and 40 years.Half held a doctoral degree and had more than 20 years of work experience.Over 58% of participants held a senior professional title (Table 2).

Results of Delphi consultations
The first round of consultations resulted in an increase of items from 25 to 27: five new items were suggested while three were removed (Table 3).The three items that were suggested by some experts for removal all had low levels of expert agreement.Wording changes were also suggested by the experts for nine items to reduce ambiguity and improve clarity (Supplementary Table 1).The four core functions (domains) remained unchanged.
The first round of Delphi consultations already achieved an I-CVI of 0.83 (22/25) and an (S-CVI)/average of 0.98, exceeding the recommended value.
The second round of consultations led to language modification of two items.One item was removed because it failed to reach agreement among the experts in both rounds of consultations (Table 2).This resulted in a final version of the NPRS, containing 26 items, measuring nurse patient understanding and respect (8 items), nursepatient trust (4 items), nurse-patient communication (8 items), and nurse's help and guidance to patients (6 items).The second round of Delphi consultations already achieved an I-CVI of 0.83 (22/26) and an (S-CVI)/average of 0.99, exceeding the recommended value.

Characteristics of survey participants
Of the 620 clinical nurses surveyed, 88.1% were female and 46.0%aged between 26 and 35 years.Most were married (53.2%), obtained a university degree (59.0%), and worked in internal medicine (55.6%).Almost half (49.0%) had over five years of work experience and 70.6% held an intermediate or senior professional title.The two subdivided samples had slightly different characteristics of study participants (Table 4).

Structural adjustment of the scale
The KMO (0.903) and Bartlett test of sphericity (p < 0.001) indicated appropriateness of the subsample (n = 330) for EFA.The EFA extracted five factors: nursing behavior; nurse understanding and respect for patient; patient misunderstanding and mistrust; communication with patient; and interaction with patient.The five factors explained 68.06% of the total variance.Three items (item N7, N9, N16) with low factor loadings or cross loadings were removed, resulting in a 23-item NPRS (Table 5).The complete NPRS scale is shown in supplementary Table S3.

Construct validity
The KMO (0.902) and Bartlett test of sphericity (p < 0.001) indicated appropriateness of the subsample (n = 290) for CFA.Excellent fitness of data into the five-factor structure in line with the EFA was found: χ 2 /df = 2.431, GFI = 0.933, TLI = 0.923, CFI = 0.939, IFI = 0.923, and RMSEA = 0.070.The vast majority of items had a factor loading greater than 0.70 on its respective domain (Supplementary Table S2).

Convergent and discriminatory validity
Convergent validity of the scale was confirmed by the CFA (n = 290), as indicated by the greater than 0.7 CR and greater than 0.5 AVE (Table 6).
The five domains were moderately correlated.The square root of the AVE value of each domain generated from the CFA (n = 290) was much greater than its correlation coefficients with other domains (Table 6), indicating good discriminant validity between dimensions.

Cronbach's α
High levels of internal consistency were found for the entire scale and its five domains, as indicated by the higher than 0.7 Cronbach'α coefficients (Table 7).

Known group validity
There were statistically significant differences in the NPRS scores by gender and working experience (Table 8).Male nurses had lower scores (indicating poorer relationship) in two domains: patient misunderstanding and

Discussion
The current research represents an attempt to provide a clear conceptualization and a reliable and valid scale measuring the comprehensive nurse-patient relationship in China.This research closely followed the best practice in scale development, involving a series studies covering the generation of dimensions and initial items, verification of the content, refinement of the scale, and reliability and validity testing of the scale.Previous studies have endeavored to assess the nurse-patient relationship through specific theories [18,46,47].the nature of the nurse-patient relationship.The nursepatient relationship scale developed in this current study offers a comprehensive tool by incorporating and refining dimensions and items derived from previous studies.The results showed that the NPRS developed by our research has good reliability and validity.It supports a multi-dimensional construct, with Cronbach's alpha of the scale and its five domains well exceeding the acceptable value of 0.7.Good content and construct validity are demonstrated through expert consensus and psychometric tests.
The NPRS has captured all of the essential elements of nurse-patient relationship as measured by the existing measurement tools, including trust [18,48], communication and interaction [46,[49][50][51], and respect and humanistic care [47].It covers both positive and negative behavioral reflections of the nurse-patient relationship, and puts nursing responsiveness, care process, and care outcomes at the core of the relationship.Mutual understanding, trust and respect provide the foundation for a positive nurse-patient relationship [27], which enables positive behaviors and interactions between the two to ensure good care outcomes.
The NPRS can help managers and policymakers to better respond to the call for patient-centered care.Increasing tensions in the relationship between nurses and patients due to various reasons have been observed worldwide [52], prompting calls for improving work and cultural environments.In this current study, we found that patient complaints are associated with poorer nursepatient relationship, characterized by patient misunderstanding and distrust in nurses.Indeed, experiencing patient complaints reduces job satisfaction and the quality of working life of nurses [53].Nurses facilitate care through frequent and direct contact with patients and their families in almost all healthcare settings, particularly in hospitals [54].Patient demands and expectations have never been so high due to the rapid technological advancement and increased affordability of care [55].What follows is the increase in the workload and the high pressure imposed on nurses [56].Constant and chronic occupational stress produce burnout, a prominent characteristic of nursing work [57].Study shows that the inverse relationship between physician burnout and patient safety affects nurse-patient relationship [58].On the other hand, patients may take improved care outcomes for granted [59].Therefore, it is important to use a tool, such as the NPRS, to help nurses and their managers to identify key domains in the nurse-patient relationship for improvement.
Our findings have some policy implications on the current health system reform in China.We found that the male nurses have worse relationship with patients than their female counterparts.This may reflect the structural inequality in gender division of work: Female nurses take most of the care tasks [60].Female nurses may be more sensitive than their male counterparts, have stronger empathy, communication and caring characteristics, and pay more attention to emotional communication [61].A study on the humanistic care of male nurses showed that male nurses expressed humanistic care differently from female nurses.Female nurses were more inclined to use their unique mother-like image to care for patients, while male nurses mostly used professional behaviors to care for patients [62].There is a need to address the gender inequality and strengthen the communication competency of male nurses.In the current study, we found that longer work experience is associated with a better nurse-patient relationship, in terms of nurse understanding and respect for patient and interaction with patient.Benner argues that rich life experience and increased situation awareness can help nurses to better manage nurse-patient relationship [63].Empirical evidence shows that nursing students can obtain both professional and personal growth, such as a rise in confidence and self-esteem, through accumulated experience in interactions with patients [64].However, professional and managerial support is equally, if

Limitation
The current study has some limitations.The study sample was drawn from one hospital.Future studies should expand participants to a more representative sample.It is also important to examine the tool from patient perspective.The NPRS was developed under the context of the Chinese health system.Cross-cultural adaptation is needed should it be used in different health system settings.

Conclusion
The 23-item NPRS is a valid tool measuring the comprehensive relationship between nurses and patients under the context of the Chinese health system.It measures five domains: nursing behavior, nurse understanding and respect for patient, patient misunderstanding and mistrust in nurse, communication with patient, and interaction with patient.The NPRS presents an opportunity for nurses and their managers to reflect and identify key domains in nurse-patient relationship for improvement.

Table 1
Conceptual framework guiding the development of the nurse-patient relationship scale

Table 3
Results of expert consultations (n = 12)

Table 4
Sociodemographic characteristics of study participants

Table 5
Results of exploratory factor analysis (n = 330)

Table 6
Composite reliability and discriminant validity of the scale (N = 290)